Inspection on 16/07/07 for Stansfield Hall

This inspection was carried out on 16th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Stansfield Hall 30/07/09

Stansfield Hall 10/07/08

Stansfield Hall 13/11/06

Stansfield Hall 26/04/06

Stansfield Hall 17/10/05

Stansfield Hall 14/06/05

Stansfield Hall 07/10/04

Stansfield Hall 14/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Stansfield Hall Stansfield Hall Temple Lane Littleborough Lancashire OL15 9QH Lead Inspector Jenny Andrew Unannounced Inspection 16th July 2007 08.15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Stansfield Hall DS0000052796.V343911.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Stansfield Hall DS0000052796.V343911.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stansfield Hall Address Stansfield Hall Temple Lane Littleborough Lancashire OL15 9QH 01706 370096 F/P 01706 370096 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Rajanikanth Selvanandan Post vacant Care Home 22 Category(ies) of Dementia (1), Old age, not falling within any registration, with number other category (21) of places Stansfield Hall DS0000052796.V343911.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 22 service users to include: up to 21 service users in the category of OP (Older People) not falling within any other category; up to 1 named service user in the category of DE (Dementia) under the age of 65 years) 13th November 2006 Date of last inspection Brief Description of the Service: Stansfield Hall is located approximately two miles from the centre of Littleborough. The home provides 14 single and four double bedrooms, all of which were let as singles at the time of the inspection. Access to the home is up two steps, although there is good ramped access to the side of the home via the conservatory. Grab rails are provided at each side of the steps. All accommodation is on ground floor level. For safety reasons there is limited access to gardens. A small patio area is provided and is used by residents in fine weather. Parking for approximately eight cars is provided, with further onstreet parking available as needed. There are a number of shops nearby but they are not easily reached by residents. A regular bus service to Rochdale and Todmorden stops close to the home. The most recent Commission for Social Care Inspection (CSCI) report is available in the entrance area and the Service User Guide advises residents and their relatives of this. At the time of this inspection, weekly fees were £333.58 rising to £450.00, the higher fee being for double rooms let as singles. Additional charges are for hairdressing, chiropody, newspapers, dry cleaning, private telephone line rental/calls, and external activities in the form of a small donation for transport. Stansfield Hall DS0000052796.V343911.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report has been written using information held on The Commission for Social Care Inspection (CSCI) records and from information obtained on this visit. This site visit to Stansfield Hall took place over seven hours and the home had not been told beforehand that the inspector would visit. The inspector looked around parts of the building, checked the records kept on residents to make sure staff were looking after them properly, as well as looking at how the medication was given out. To find out more about the home the inspector spoke with the owner, eight residents, the senior in charge, two carers, a domestic, the cook and one visitor. Comment cards asking residents and relatives what they thought about the care at Stansfield Hall had been given out before the inspection. Seven relatives had filled the cards in and returned them to the Commission for Social Care Inspection. At the time of the inspection there was no registered manager in post; she had left on 2 July 2007. The owner had recruited a new manager who would be starting work at the home at the beginning of September 2007. Until she starts work, the owner is managing the home. What the service does well: Before new service users came to live at Stansfield Hall, the manager had made sure they had all the right details about them, so that they were clear that the home was the right place for them to live and that their needs would be met. The staff team were giving good care to the residents who praised the staff saying “they’re excellent”, “look after me well”, “really good”, “nice girls”, “are very kind to me”, “fine”, “very good” and “very satisfied with the care given”. Food provided was nutritious, varied and the menu included a variety of meat, fish, fruit and vegetables. Choices were available at all meals. Residents’ comments about the food were “it’s very good and no complaints at all”, “really good and you always get a choice”, “if its something you don’t like the cooks will make you something else”, “excellent” and “not bad at all taking into account the cooks have to cater for different tastes”. Stansfield Hall DS0000052796.V343911.R01.S.doc Version 5.2 Page 6 The home had an activity worker who visited twice a week and several of the residents really looked forward to these visits. She had a varied activity programme that took into account the differing needs and abilities of the residents. When she did not visit, the staff spent time chatting to residents in lounges and in their bedrooms. Although there had been some changes in the staff team, many of the staff had worked at the home for several years and got to know the residents’ routines and likes and dislikes. The home was good at making sure service users’ health was well looked after and the residents felt safe and cared for. What has improved since the last inspection? What they could do better: The owner needed to learn how to work co-operatively with the Social Services Department should any future protection of vulnerable adult investigations be necessary in the future. Whilst the owner had had the central heating boiler serviced, one resident was still experiencing problems in getting hot water to wash in a morning and this needed to be put right. Whilst a fire risk assessment had been done at the time of the last visit, not all the recommendations in the report had been addressed in order to ensure the building was as safe as possible for the residents and staff who worked there. The building was in need of re-decorating and refurbishing so that the residents would have a more pleasing environment in which to live. Stansfield Hall DS0000052796.V343911.R01.S.doc Version 5.2 Page 7 Other than one resident meeting that had been held, there was no quality monitoring system in place to check on how well the home was delivering a service to the people living there. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Stansfield Hall DS0000052796.V343911.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Stansfield Hall DS0000052796.V343911.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents were assessed before coming into the home to ensure their needs could be satisfactorily met. Standard 6 was not assessed as the home did not accommodate intermediate care residents. EVIDENCE: Assessments for three residents were checked, one for a resident who had recently been admitted for a short stay. This person was spoken to during the visit. She said the manager had visited her whilst in hospital and asked her a lot of questions about what she could do for herself and what she needed help with. She said she had found her stay very beneficial and that she was now preparing to move back to her own home. The assessment was quite detailed Stansfield Hall DS0000052796.V343911.R01.S.doc Version 5.2 Page 10 and covered all daily living tasks, as well as recording details of mental state, past medical history and medication. A file for a resident who had been admitted over the past 12 months was seen and this also contained evidence that the person had been visited before coming into the home. The file recorded the person did not wish to give any social background and this had been signed by the resident. A file for a resident who had moved into the home in 2001 was also checked but the service delivery agreement was not in the file. The inspector was advised this would have been filed away, due to the length of time the person had lived at the home. The majority of the staff had undertaken dementia care training so they would know how best to care for people with confusion. Stansfield Hall DS0000052796.V343911.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The health and personal care needs of residents’ were recorded in detail on their care plans so the staff would know exactly what care each person needed. EVIDENCE: Care plans were in place for all the permanent residents being accommodated. Three files and care plans were checked. One care plan was for a respite stay resident, one was for a resident who had lived at the home for just over a year and the other for a resident who needed a lot of care and support. Stansfield Hall DS0000052796.V343911.R01.S.doc Version 5.2 Page 12 The file for the person on a short stay contained a detailed assessment that set out what help the person needed but it did not contain a plan of care. The senior carer on duty said the previous manager had instructed staff to use the assessment as a care plan, due to her only being a short stay resident. In future, it is recommended that care plans for respite stay residents are formulated from the initial assessment. When checking on what date residents had been admitted to the home, this was not always clearly recorded and the owner should ensure this information is recorded on each person’s personal record sheet. The care plans for the other two residents were detailed and contained all the information needed to provide the right care for these people. One of these residents was spoken to and the care she described as needing was as was recorded in her care plan. She was particularly praiseworthy about the previous manager whom she said would visit their room daily to make sure everything was in order and to check the care given was to their satisfaction. She was also complimentary about the care and support she had received from the staff, following a recent bereavement. The third file was for a resident who needed quite a lot of personal care support from the staff. The care plan set out what help was needed and what the person could do for their selves. Her care plan had recently been updated. The plan also recorded about ensuring the staff maintained her privacy and dignity when assisting with personal care tasks. The care plans were all up to date and had been last reviewed at the end of June 2007. It was however, noted that monthly reviews were not always taking place and the owner should ensure staff are vigilant in this area. All the residents spoken with felt the staff were looking after them well. One person said they would like more than one bath a week and this information was passed to the owner of the home. One resident said that after speaking to the previous manager about not always having her legs creamed and eye drops given, her care had improved considerably. One resident said, “the staff are always there to help you if you can’t do something for yourself”. Another said, “you only need to ring your bell and the staff come quickly”. Risk assessments were undertaken for any identified areas of risk. Assessments in place for the two permanent residents included moving/handling, falls, nutrition and skin. One file had an infection control risk assessment in place and the other contained a self medication assessment. Stansfield Hall DS0000052796.V343911.R01.S.doc Version 5.2 Page 13 The assessments were detailed and set out the action staff needed to take to reduce the identified risk areas. The file for the resident on a short stay only contained a risk assessment in respect of falling out of bed but the assessment did not highlight any other risk areas. The owner should be vigilant in respect of this area for people on short stay visits. District nurses were only visiting to keep an eye on certain residents and noone was being currently being treated for pressure sores. The senior care assistant said that more referrals were being made to health care professionals and gave examples of where the dietician, falls co-ordinator and someone from the mental health team had visited to offer advice. On the day of the inspection, one resident was quite poorly and a GP visit was requested. The doctor’s instructions were passed over on shift handover and this person had a fluid and dietary chart in place so that the staff could closely monitor how much the person was eating and drinking. When any health care professionals had visited the home, their instructions were recorded on the resident’s care plan file. This resident had been due to attend an out-patient appointment. The visit was cancelled and a new appointment made for her. Residents’ weight was being closely monitored and the Malnutrition Universal Screening Tool (MUST), which highlights when action needs to be taken to increase a resident’s weight, was in place. The cook was knowledgeable about which residents needed to be tempted to eat and this was apparent on the day of the inspection. One quite frail resident really liked rice pudding and if she did not eat the pudding that was offered, the cook had some tins of rice pudding, which she made sure she was given. Fortified drinks prescribed by the GP’s were also being given. The relatives’ returned comment cards were positive in respect of the care given. The following comments were made: “they care for my mother well”, “residents are always treated with care and respect”, “both my father and I have been very satisfied with the care given at the home and the staff are particularly warm and friendly”, “my relative says she has everything she wants at Stansfield Hall and she is happy there” and, “the manager has been very prompt in getting the doctor when my mother has had an infection”. A monitored dosage system was in place and staff were following the home’s policy. Senior staff, trained in giving out medication, were responsible for this task. Medication Administration Records were signed when the senior had noted the person had taken the medication. There was no over-stocking of medication. Unused medication was being collected regularly and this occurred during the visit. The pharmacy representative signed the disposal sheet, a copy of which was retained by the home. The arrangements in place for controlled drugs were satisfactory. From checking the controlled drug book, it was noted only one person was in receipt of such medication. Stansfield Hall DS0000052796.V343911.R01.S.doc Version 5.2 Page 14 The home was actively promoting residents’ independence by encouraging them to manage their own medications. As part of the assessment process, residents were asked about whether they would wish to hold their own medication. Where it was assessed they were competent to do so, a risk assessment was written and signed by the resident. Evidence of this was seen on one file inspected. The assessment instructed staff to leave the tablets with the resident and then later check to see if she had taken them. Care plans recorded the need for staff to adhere to good practice in respect of privacy and dignity of residents when assisting them with personal care tasks. Following a recent Social Services Department investigation, the majority of the staff team had recently undertaken training in dignity and care. The staff spoken to were able to give examples of how they ensured residents’ dignity and privacy were upheld. These included: closing doors and shutting curtains, knocking on bedroom doors before entering, keeping a resident covered up when assisting with washing or bathing and asking discreetly if people needed the toilet. Observations made during the inspection showed residents were being assisted to transfer sensitively, able to spend as much time as they wanted in their bedrooms and they were clean and smartly dressed. Stansfield Hall DS0000052796.V343911.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 – 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents were encouraged and supported to exercise choice in their daily routines in relation to lifestyle, food and activities. EVIDENCE: The improvements in social activities, identified at the last key inspection, had been maintained. A part-time activity worker was employed for six hours a week (worked over two days) and, in her absence, staff also spent time with the residents, encouraging them to play cards or chat on a one to one basis. An activity book was being used to record both group and individual daily activities. From entries recorded, it was identified that regular craft sessions, bingo, singalongs, organ playing, hymn singing and baking/cake decorating were taking place. Stansfield Hall DS0000052796.V343911.R01.S.doc Version 5.2 Page 16 All the residents spoken to said they were satisfied with the activities provided, although several said they did not always wish to take part. As there was a choice of lounges this was not a problem. One person felt that more exercise would be beneficial, such as armchair exercises or simply being assisted to walk around the home so her joints would not stiffen up. Two people said how much they enjoyed the twice weekly sessions with the activity worker whom they described as, “brilliant” and “excellent at her job”. On a monthly basis, one person who had a sight impairment was accompanied to the local club for sensory impaired people and she said she really enjoyed going there. Three or four residents had been escorted to the Coach House in Littleborough in March to a Lifeboat fund raising teaparty. Significant celebratory days such as Christmas, Valentine’s Day and Easter had also been celebrated. The residents who preferred to spend time in their bedrooms said they were always told when any entertainment had been arranged. One resident said a group of children had recently visited the home to sing to them. The activity worker’s husband also played the organ and several residents enjoyed this. All the residents spoken to felt the staff respected their preferred routines and lifestyles and evidence of this was seen during the inspection. They could get up when they wanted, dress how they liked, choose to eat where they were sitting, in their bedrooms or at the dining tables, had the choice of various lounges and could join in with social activities or not, dependent upon how they were feeling. Relative comment cards indicated the staff assisted residents to keep in touch with their relatives. Residents were able to receive visitors in private or choose to remain in the lounge. If residents wanted privacy without using their rooms, the conservatory was used. The residents spoken with were satisfied with the arrangements in place with regard to their religious needs. One resident attended church weekly, a church visitor arranging this on her behalf and weekly communion was arranged for one or two residents. In addition, church members of the Vine Fellowship visited the home on a fortnightly basis when a service would take place. The statement of purpose included contacts for local advocacy services. Those residents spoken with were happy with the way the home handled their finances. Stansfield Hall DS0000052796.V343911.R01.S.doc Version 5.2 Page 17 Feedback from residents spoken to was very positive about the meals they received. A new cook, who had worked at the home for about three months was on duty at the time of the visit and she had already familiarised herself with the likes and dislikes of the resident group. Four weekly rotational menus were in place which showed a variety of meat, fish, fresh and frozen vegetables were served daily. The cook said the other cook and herself were going to review the menus as she had identified that some of the meals were not particularly enjoyed by the residents. She said they would be consulting further with the residents before the menus were changed although some suggestions had already been made at the last resident meeting. At breakfast residents could have more or less anything they liked. One person had a fried egg and two others enjoyed a boiled egg every day, one person enjoyed a banana and grapefruit segments. A choice of two snack meals were offered at lunch time with a more substantial dessert. At tea-time a substantial hot meal was served, together with an alternative and a lighter dessert. On the day of the inspection, the evening meal was sampled by the inspector. It was home-made chicken casserole with carrots added and sliced potatos. The meal was hot and very tasty. This was followed by fruit and cream. One resident spoken to said she had requested the jacket potato filled with cheese as she really enjoyed this. Another said salads could be requested any time. At lunch the majority of the residents enjoyed spam and chips although some residents enjoyed a plate of chips without the spam. The cook offered alternatives when residents did not like what was on offer and there was always an alternative meal on both lunch and tea menus. This was followed by coconut sponge and custard. Following breakfast, one resident asked for some ginger biscuits and these were provided without any fuss. Sufficient drinks were served throughout the day, with jugs of juice being available in the communal lounges. Bowls of fruit containing apples, pears and oranges were provided in the lounges so that residents could help themselves. The special dietary needs of the residents were being met with low fat, soft and diabetic diets being followed. One resident who needed a soft diet was sensitively assisted to eat by the staff on duty. She had scrambled egg with cheese at lunch time and at teatime she was able to enjoy the casserole which was pureed. Residents could choose where to take their meals. Several people liked to stay in their rooms for one meal and sit in the dining room for their other meals. Some people took all their meals in their bedrooms. Two residents regularly ate their tea together in one room. Stansfield Hall DS0000052796.V343911.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 – 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The owner and staffs’ knowledge about adult protection issues had been found lacking which could result in the home failing to protect residents from harm or abuse. EVIDENCE: The service user guide, which each service user had a copy of, contained the home’s complaints procedure. Feedback from speaking to the residents, indicated they knew how to make a complaint. They said now that the manager had left, they would report any concerns or grumbles to the owner who was always around. They all said he was easy to talk to and they felt he would put things right for them. One resident said “if you have any complaints, you just tell the staff and they’ll sort it for you”. They all felt the home was a safe place in which to live. The Commission for Social Care Inspection had not had cause to investigate any complaints in the home since the last key inspection and no complaints had been recorded by the home. Stansfield Hall DS0000052796.V343911.R01.S.doc Version 5.2 Page 19 A procedure for responding to allegations of abuse was available, as was an inter-agency procedure. Since the last key inspection, the Rochdale MBC Social Services Department had been involved in the investigation of an adult protection issue in respect of poor care practice. Their investigation, together with the outcome had been shared with the Commission for Social Care Inspector who had attended two review meetings. The owner of the home had not been conversant with how such an investigation should be conducted and had failed to respond to the Social Services Department promptly and appropriately. It was felt, by both the Social Services staff and the CSCI inspector that he had failed to appreciate the seriousness of the investigation and had not followed the guidelines. The outcome of the investigation was proven resulting in an action plan being drawn up to address the identified shortfalls. The provider was instructed to undertake protection of vulnerable adult training within three months of the last review meeting on 31 May 2007, in order to ensure that in the future he was conversant with how to conduct protection investigations. He confirmed that he had booked on the course on 23 August 2007. The majority of staff had attended Protection of Vulnerable Adult (POVA) training, which had been organised by the Social Services Training Department or in-house training done by the previous manager. The staff spoken to understood the importance of reporting malpractice, and the different types of abuse. All staff had been issued with a copy of the home’s Whistle Blowing policy. Stansfield Hall DS0000052796.V343911.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. There had been no upgrade to the décor or furnishings in the communal areas of the home for three years and whilst this did not pose a risk to residents, it did not create a pleasing environment to live in. EVIDENCE: There was no maintenance programme in place and the owner confirmed that no re-decoration or refurbishment had taken place since he had initially redecorated the home when he took over from the previous owners approximately four years ago. He had, however, applied for a capital grant from the Local Authority which was being processed and which he was proposing to use to re-decorate, fit new carpets in communal areas and purchase new furniture. Stansfield Hall DS0000052796.V343911.R01.S.doc Version 5.2 Page 21 Whilst the owner had recently appointed a handyman to work at the home, this person had only stayed for a very short time before leaving. A new handyman had been interviewed and was due to commence work as soon as a satisfactory Criminal Record Bureau check had been obtained. It was noted that the conservatory roof had originally been painted to try and reduce the heat in the room. The paint had now peeled off in patches and it now looked dirty and unsightly to anyone using this room. A visit by the Environmental Health Officer had taken place when several areas were identified as requiring attention. A report was seen for the follow up visit when it was recorded that all areas had been satisfactorily addressed. At the last key inspection, a requirement was made in respect of addressing the shortfalls that had been outlined in a fire risk assessment document, following a visit by an independent company. The owner could not find the fire risk assessment but confirmed that the majority of the work had been completed. Due to the absent report, this could not be verified. The owner should now write to the Commission for Social Care Inspection, confirming that all relevant works have been completed in order to ensure the safety of the people living and working at the home. Residents spoken with were satisfied with their bedrooms and those seen were personalised with people’s own furniture, pictures and ornaments. One resident said she had been able to bring in all her own furniture, which had made her feel more settled and at home. Upon walking around the building, it was evident that communal areas, corridors and bathrooms/toilets were in need of re-decoration. In addition, the carpets in the communal lounge areas were stained and faded in places. The domestic said the stains would not come out even when the carpets were cleaned. The owner said these areas would be addressed as part of the upgrading programme when the capital grant money had been secured. He also said he was hoping to convert one of the bathrooms into a walk-in shower room. A requirement had been made at the last inspection for the new en-suite toilet to be completed and for new sealed floor covering to be fitted in toilet 15. The en-suite toilet had been almost completed, except for the painting of the wood surrounding the wash hand basin and the tiling around the basin was incomplete. The owner said he would ensure this was finished. The flooring in the toilet had not been replaced but the owner again said he would fit new flooring when the grant money was received. Stansfield Hall DS0000052796.V343911.R01.S.doc Version 5.2 Page 22 At the last inspection, it was identified that in some parts of the home, they were experiencing problems with water temperatures not getting hot enough. The owner had contacted a new heating company, who were on call 24 hours a day and taken out a new contract with them. They had been to service the boiler and staff said that the majority of the bedrooms now had hot water. They did, however, identify that problems were still being experienced in one bedroom when sometimes, there was no hot water in a morning. The resident in this room confirmed this was a regular occurrence and that she had to wash in tepid water. The owner must now ensure that the resident in this bedroom has readily available hot water in which to wash in a morning. Since the new no-smoking Government laws had been implemented, residents could no longer smoke in communal areas of the home. It had been agreed with those who smoked that they would do so in their bedrooms with the window opened. Signage had been fixed to bedroom doors to highlight the rooms, which were occupied by people who smoked. The staff were only allowed to smoke outside the home. The building was old and therefore difficult to keep clean but there were no malodours apparent. Two domestics were employed but when checking rotas to see how many hours were provided, no ancillary rota was in place. The owner must ensure that the ancillary staff are included on staff rotas. One relative comment card recorded they thought the home needed more cleaners on duty. The domestic spoken to said they worked two days together each week so they could “bottom” bedrooms but that on a Tuesday and Sunday there was no domestic on duty. The staff confirmed they were responsible for emptying commodes and bins and for cleaning toilets when needed on these days. All but one resident said they were satisfied with the cleanliness in the home. This person felt that her bedroom should be dusted on a more frequent basis and her comment was passed to the owner of the home so that action could be taken to address this. The owner should consider giving additional hours to the domestics so that they can at least cover weekdays. Residents were observed moving around the home fairly easily and appropriate aids and adaptations were fitted in toilets and bathrooms so that people could remain as independent as possible. As the home was single storey only, there was no lift fitted. Only office accommodation was on the first floor level of the building. Infection control policies/procedures were in place, which staff were following. At meal times, staff changed into blue disposable aprons to try and reduce the risk of infection. When assisting people with personal care tasks, they wore white disposable aprons and disposable gloves. A supply of paper towels and liquid soap were in bathrooms, toilets and bedrooms, which was another way of reducing the risk of passing on infections. Stansfield Hall DS0000052796.V343911.R01.S.doc Version 5.2 Page 23 Laundry facilities were satisfactory for the number of residents accommodated. There was no laundry assistant employed and both day and night staff were responsible for the washing and ironing of residents’ clothing. Residents said there were occasions when clothing was misplaced but it was usually found fairly quickly. Stansfield Hall DS0000052796.V343911.R01.S.doc Version 5.2 Page 24 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home was adequately staffed to meet the needs of the people living there and the majority of the staff had undertaken the training needed to try and make sure they worked in a safe and competent way. EVIDENCE: Adequate staffing levels were being maintained for the number of people presently living at the home, which was 18. Three care staff, which included a senior carer, were employed on each shift with two staff on duty through the night. This was evidenced from checking rotas, speaking to carers and talking to residents. The present staff group, excluding the owner, were all white-British which reflected the make-up of the current resident group. With the exception of the owner, who sometimes worked shifts on the floor, the team were all female. The male residents spoken to said they did not mind being assisted by female staff. Stansfield Hall DS0000052796.V343911.R01.S.doc Version 5.2 Page 25 Staff turnover was low, with only one care staff and the manager having left since the last inspection. This meant that the residents received consistent care from staff whom they had got to know well. Resident feedback about the staff and how they were cared for was very positive. The staff spoken to felt that staff morale had improved and they were working well together as a team. They confirmed that before the manager had left they had started meeting with her for one to one supervision meetings and these were recorded on individuals’ files. Of the 16 staff employed, eight had completed their NVQ Level 2 training or above, making 50 of qualified staff. A further two staff were presently doing their NVQ level 2 training. In addition, the owner employed a state enrolled nurse as a care assistant. Inspection of three staff files showed that the previous manager had implemented the home’s recruitment policy and procedures. Each file contained a completed application form, two written references and proof that a full Criminal Record Bureau check had been received. Each staff member also had a training file, which showed the training each person had undertaken, together with copy certification. In one person’s file, evidence was seen that disciplinary action had been taken as a result of poor practice. It was, however, noted that, since this time, neither the previous manager, nor the owner had continued to monitor this person’s work as there was an absence of supervision notes contained in her file. In instances such as this, evidence should be recorded of the person’s performance until the person in charge is satisfied with the person’s competencies. Another file contained evidence that one person’s Criminal Record Bureau check showed they had committed a past offence. The owner said the manager had discussed this with the employee at the time but had not recorded their conversation. Such meetings should always be recorded. Due to the registered manager having left, the owner had advertised for a new manager and advised the inspector that someone had been appointed and would be starting work on 3 September 2007. There was, however, no completed application form in her file or copy certificates showing the training and qualifications she had achieved. There was a CV showing her past jobs and experience and two references which she had brought to her interview. The owner said he would be sending for references himself and that he was meeting with her the week of the inspection in order to complete the Criminal Record Bureau form. It was stressed to the owner that he should be adhering to the home’s recruitment policy, especially when appointing a registered manager. Stansfield Hall DS0000052796.V343911.R01.S.doc Version 5.2 Page 26 The previous manager had introduced Skills for Care training for new staff and the file for a newly appointed care assistant, who had recently left due to personal circumstances, showed she had almost completed the training. The owner should now ensure that in the absence of a manager, any new staff to the home should undertake the training. According to the Annual Quality Assurance Assessment form, all the staff had received a copy of the General Social Care Council, “Code of Practice”. There was no up to date training matrix in place so it was difficult to identify whether all the staff had attended the necessary health and safety training such as fire, moving/handling, food hygiene and infection control. However, in the three files inspected, there were copy certificates in place showing the staff had done all mandatory training courses. The owner also showed evidence that following the protection investigation, which had highlighted shortfalls in how people were assisted with transfers, nine care staff and the manager had attended refresher moving/handling training. Stansfield Hall DS0000052796.V343911.R01.S.doc Version 5.2 Page 27 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The home was currently being managed by the owner who did not have all the skills and knowledge required to undertake the job which may impact on the quality of the care delivered to residents. EVIDENCE: The registered manager had left a fortnight before this visit took place. During the nine months she had been at the home, she had worked hard and had introduced regular supervision with the care staff, held staff meetings, updated policies and procedures and started Skills for Care training for new staff. In addition, she had been pro-active in arranging further mandatory training for many of the staff team. Stansfield Hall DS0000052796.V343911.R01.S.doc Version 5.2 Page 28 The owner should now ensure that whilst acting as manager of the home, he continues with the progress made by the previous manager in the areas identified. In addition, when making any staff appointments he should follow the home’s recruitment policy and procedures, which did not happen when the new manager had been recruited. The owner had advised the CSCI about the manager’s departure by telephone but had not yet written in to confirm the interim arrangements. He said he would do this immediately. He said the appointed manager had experience of running a care home and had already completed the Registered Manager’s Award. This was confirmed from reading her CV but as already stated, there were no copy certificates to confirm this. Little progress had been made in respect of introducing a quality assurance and monitoring system to determine how well the home was delivering a service. One resident meeting had been held, attended by eight residents and two relatives. The minutes of the meeting were seen and it was evident that a lot of topics had been addressed, such as food, laundry and activities. More regular resident meetings should be held. No satisfaction questionnaires had yet been circulated to residents, their relatives or other visiting professionals to the home and this is an area that needs to be addressed. Whilst the residents spoken to said they were happy with the arrangements they had in respect of the way their money was handled, it was not possible to check the finance system. The owner arrived at the home at approximately 14:00 on the day of the inspection, having driven up from London and come straight to the home. As he had not been home, he did not have the keys to access the money and the finance sheets so the inspector could check that balances were in order. As previously stated, it was difficult to ascertain if all the staff had completed their mandatory training but the files inspected showed this to be the case. The Annual Quality Assurance Assessment (AQAA) form recorded that all maintenance checks were up to date. Random samples of gas certificate, fire appliances and bath hoist servicing documents confirmed this was so. Stansfield Hall DS0000052796.V343911.R01.S.doc Version 5.2 Page 29 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 x x X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 2 x x 3 Stansfield Hall DS0000052796.V343911.R01.S.doc Version 5.2 Page 30 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP19 Regulation 23(2)(j) Requirement Timescale for action 24/08/07 2 OP27 17(2) 3 4 OP31 8 23(4)© OP38 The owner must ensure there is hot water in a morning in bedroom 30 so that the resident can enjoy a proper wash. All ancillary staff working at the 24/08/07 home must be recorded on a rota so it is clear when they are on duty and what hours they are working. The owner must submit an 31/10/07 application for the new manager to be registered with the CSCI. The owner must ensure that all 28/09/07 the shortfalls identified in the fire risk assessment are addressed to make sure the home is safe for the people living and working there. (Previous timescale of 31/01/07 not met). Stansfield Hall DS0000052796.V343911.R01.S.doc Version 5.2 Page 31 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations Residents on respite stays should also have a care plan in place so that the staff will know exactly what the person needs assistance with and risk assessments should be undertaken if risk areas are identified. The date of admission of each person should be recorded on the person’s personal detail sheet. Staff should organise armchair exercises and also encourage residents to take short walks around the home either independently or with staff dependent upon abilities and risk assessments. The owner should have a maintenance plan in place addressing the areas that need to be re-decorated and the furniture which is need of replacement. The sink surround in the en-suite toilet should be painted and the tiling completed. New sealed flooring in toilet 15 should be fitted. Following disciplinary meetings, staff should be supervised until the owner is satisfied they are working satisfactorily and competent to do their jobs. Where Criminal Record Bureau checks show the person has a previous conviction, in line with good employment practice, it should be discussed with them and the outcome of the meeting recorded. An up to date training matrix should be in place so that the owner can quickly identify exactly what training staff have done, what they still need to do and when refresher training is due. More regular resident/relative meetings should be held and minutes recorded and held on file. The owner must implement a quality assurance system so that he can monitor whether residents and/or their relatives are satisfied with the service. Feedback should obtain feedback about the service from a wider range of people, e.g., relatives, professional visitors to the home. 2 3 OP7 OP12 4 5 6 7 8 OP19 OP19 OP19 OP29 OP29 9 OP30 10 11 OP33 OP33 Stansfield Hall DS0000052796.V343911.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Stansfield Hall DS0000052796.V343911.R01.S.doc Version 5.2 Page 33 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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